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Arch. Dis. Childh., 1967, 42, 174.

Arterial Oxygen Studies in Premature Newborns with


and without Mild Respiratory Disorders
MARCELLO M. ORZALESI, MODESTO MENDICINI, GIOVANNI BUCCI,
ANTONIO SCALAMANDRP, and PIER GIORGIO SAVIGNONI
From the Department of Paediatrics, University of Rome Medical School, Rome, Italy

Arterial oxygen studies in full-term infants at


various ages have been made by numerous authors
(Stahlman, 1957; Weisbrot, James, Prince, Holaday,
and Apgar, 1958; Graham, Koeff, Tsao, Sloan, and
Wilson, 1959; Reardon, Baumann, and Hadded,
1960; Oliver, Demis, and Bates, 1961; Nelson,
Prod'hom, Cherry, Lipsitz, and Smith, 1963).
Few similar studies have been performed on
premature infants (Graham, Reardon, Wilson, Tsao,
and Baumann, 1950; Prod'hom, Levison, Cherry,
Drorbaugh, Hubbell, and Smith, 1964). In 1965
Moss, Emmanouilides, Rettori, Higashimo, and
Adams published data from premature infants in the
first 72 hours of life, showing that 'normal' prematures had lower arterial oxygen tensions than adults,
and that this difference was accentuated in prematures with 'mild respiratory distress': the criteria for
classifying the babies as 'normal' were not explained
in detail and the type and the severity of respiratory
distress were not defined clearly. Furthermore, no
studies were performed in infants of more than 72
hours.
The present paper provides data on arterial blood
gases in normal premature infants from 3 hours to
40 days of age. The criteria for normality were
based on clinical grounds and on chest x-ray findings.
In addition, data from premature infants with
tachypnoea and with transient mild respiratory
distress, but without x-ray changes suggestive of
pneumonia or hyaline membrane disease (Iannaccone, Bucci, and Savignoni, 1965), are also
presented.
Material and Methods
The study includes 59 premature infants admitted
between December 1964 and February 1966, and
ranging in age from 3 hours to 40 days; the birthweight
ranged between 1130 and 2480 g., and the gestational age
from 28 to 40 weeks. All were admitted to the premature unit within 24 hours of birth. A physical examinaReceived August 25, 1966.

tion and two antero-posterior chest x-ray films were


taken on admission on each baby; Silverman's retraction
score (Silverman and Andersen, 1956), the respiratory
rate, skin colour, heart rate, and other physical findings
were recorded every 3 hours during the first two days of
life (or longer if abnormal) and less frequently thereafter.
The chest x-ray films were evaluated separately by the
radiologist and were graded according to previously
published criteria (Iannaccone et al., 1965). On the
basis of the clinical and radiological findings the infants
were divided into 3 groups (Table I).
The first group included 40 infants with birthweights
between 1260 and 2480 g., who were both clinically and
radiologically normal (i.e. Silverman's score < 2,
respiratory rate < 65/min., skin colour normal, cardiac
murmurs absent, and, on x-ray films, absence of vascular
engorgement, atelectasis, emphysema, air bronchograms, or fine granularity).
The second group comprised 14 infants with birthweights between 1130 and 2260 g., who had respiratory
rates above 65/min. for at least 24 hours and no other
signs of respiratory or cardiac disorders (Silverman's
score always < 2). The chest x-ray films were normal
in all except 2 babies in whom mild patchy atelectasis
was present.
The third group comprised 5 infants with birthweights
between 1790 and 2310 g., who had Silverman's scores of
3 in the first 24 hours of life and respiratory rates above
60/min. during the first 48 hours. The chest x-ray films
showed mild patchy atelectasis in 2 babies and were
normal in 3.
None of the infants studied had the radiological
features of hyaline membrane disease (decreased
translucency, reticulo-granular pattern, and air broncho-

gram) or pneumonia (coarse nodularity, severe patchy


atelectasis, and emphysema), and all recovered and
survived. Respiratory distress in infants of the second
and third group was always mild, so that, on clinical
grounds, it was judged safe to study them while breathing
room air.

Thirteen normal adults were also studied and served


as controls.
Using the techniques described in previous papers

(Scalamandre, Bucci, Orzalesi, Mendicini and Savignoni,


1966; Bucci, Scalamandre, Savignoni, Orzalesi, and

174

Arterial Oxygen Studies in Premature Newborns

175

TABLE I

Number of Subjects, Average Birthweight, Gestational Age, Average Silverman's Score, and Respiratory Rate
at Different Ages, in the 3 Groups of Prematures Studied
Group
Normal
Tachypnoea
Mild RDS

No.

..
..
..

40
14
5

Birthweight

Gestational
Age
(wk.)

1*76
1-72
(1 13-2326)
2-02

34*5
33 6
(31-38)
(32-37)

(kg.)
(kg.)

(1 26-2-48)
(1-79-2-31)

(28-40)

1-6 Hours
7-24 Hours
25-48 Hours
49-72 Hours
73-96 Hours
___.___
RespRespRespRespRespScore iratory Score iratory Score iratory Score iratory Score iratory
Rate
Rate
Rate
Rate
Rate
08
56
06
52
05
51
02
48
46
02
1 4
1 2
71
69
1.1
66 0| 6
58
0D4
54
3-0
67
2-4
64
1.0
57
0-8
55
-

Mendicini, 1966), 104 samples of arterial blood were


taken from the radial artery, 22 from the temporal artery,
and 8 from the umbilical artery. The infants breathed
room air and remained generally quiet during the
procedure.
All blood analyses were performed within 10 minutes
of sampling. Arterial pH and base excess (BE) were
measured at 37. 50 C., using the Astrup apparatus*
(Astrup, Jorgensen, Siggaard Andersen, and Engel,
1960) and carbon-dioxide tension (PaCO2) was derived
from the Siggaard Andersen nomogram, after correcting
for the amount of unsaturated haemoglobin (Siggaard
Andersen, 1962). Arterial oxygen tension (Pao2) was
measured at 37. 5 C. with a Clark electrode*, and
oxygen saturation (SaO2) was calculated from the Pao2
and pH, using the foetal blood 02 dissociation curves at
various pHs, obtained by combining the data of Edwards
and Ross (1959) and Nelson, Prod'hom, Cherry, and
Smith (1964); SaO2 in adults was derived from standard
published curves (Rahn and Fenn, 1955). Haemoglobin
concentration was measured with the cyanmethaemoglobin method.
Almost all determinations were carried out in duplicate, and all values of pH, PaCo2, and PaO2 were corrected
for the temperature of the babies using published

correction factors (Bradley, Stupfel, and Severinghaus,


1956; Adamsons, Daniel, Gandy, and James, 1964).
Venous admixture (VA) in air was also calculated
using the standard shunt equation (Comroe, Forster,
Dubois, Briscoe, and Carlsen, 1962):
[blood

VA% = 02 content of pulm. capillary blood -02 content of arterial

02 content of pulm. capillary blood -02 content of mixed


[venous blood

Oxygen content of arterial and pulmonary capillary


blood was calculated by multiplying the amount of
saturated haemoglobin by 1 * 34. The amount of
oxygen in mixed venous blood was assumed to be 4 vol.
% lower than in arterial blood (Strang and Macleish,
1961). The Sao2 of pulmonary capillary blood was
derived from the foetal blood 02-dissociation curve,
*

Astrup micro-equipment type AME 1 and oxygen monitor type


PHA 928 and Po2 electrode type E5044; Radiometer, Copenhagen,
Denmark.

assuming the pH and Po2 of capillary blood to be equal


to the arterial pH and alveolar Po2 (PAo2) respectively*.
The PAO2 was calculated from the alveolar air equation
(Comroe et al., 1962):

PAO2 = P1o2 - PaCO2 x (F1o2 + 1 F-oa)


Plo2 and FIo2 are the oxygen tension and concentration

in the inspired air, and R is the respiratory quotient.


The values of R published by Adams, Fujiwara, Spears,
and Hodgman (1964) were used for premature infants
and an R value of 0 85 was assumed for adults.
-

Results
The main clinical features of the infants studied
are summarized in Table I. There were no
appreciable differences in birthweight and gestational age between the first and the second group, while
in the third group the average birthweight was
slightly higher. The average respiratory rate in the
second and third group, and the Silverman's score
in the third group, were higher than normal in the
first two days of life and decreased gradually thereafter.
Samples from the right and left radial and
temporal arteries, and the umbilical artery, have
been analysed together because Moss et al. (1965)
have found no appreciable right-to-left ductal
shunts in similar infants.

Normal infants. The results obtained in the


40 normal premature infants are shown in Table II
and in Fig. 1, 2, and 3; the data from normal adults
are included for comparison.
The pH, PaO2, and SaO2 at 3-5 hours of age were
lower than later, but this age-group included only 4
subjects and allows no conclusions.
After 5 hours of life there were no appreciable
* When breathing air, the assumption that PA02 = P02 of pulmonary capillary blood may introduce an error in the calculation of VA;
the latter may be overestimated and include the effect of a diffusion
defect and/or of a ventilation/perfusion imbalance.

Orzalesi, Mendicini, Bucci, Scalamandre, and Savignoni

176

TABLE II
Infants Studied at Different Ages (Means * SD)
Premature
in
'Normal'
Arterial Blood Values
3-5 Hr.

..
Number
..
Age (mean)
PaO2 (mm. Hg)

SaO2(%)

.*

VA(%)

..

..
..
..

4
4 hr.

59*5t

7-7
91 3t
1-7

19-5*
4-5

..

6-12 Hr.
9
8 hr.
69 7*
11-8

95-2*

1-2

14-5*

13-24 Hr.
12
20 hr.

67*Ot

15-2

95.3*

2-1

16-3*

7329*
0-038

4-8
7*425
0-072

6-3
7*464
0-064

47.3*

28*2t

27*2t

BE (mEq/l.)

3..
-37*

-7*

Hb(g./100ml.)

..

pH.
.

Paco2 (mm. Hg)

8-5

1-5

16*2t

1-7

6-9

3-1

16-lt

2-8

8-4
3-2 *
3-3
16 0*
2-3

Values statistically different from adult controls: * = p < 0 05,

changes in S5o2, except for a small increase at 11-40


days. The values at all ages were significantly
lower than in adult controls (Table II).
The P5o2 in infants up to 40 days of age was also
significantly lower than in adults (Table II); there
was, however, a significant rise in P5o2 from 6-24
hours to 3-10 days of life (p < 0 05).
Venous admixture in air (VA) during the first and
second day of life was significantly greater than at
3-10 days (p < 0 01 and p < 0 05).
I0o

100

90
bO

80

70-

25-48 Hr.
22
35 hr.

72*5t
20-9

950*t

5-10 Dy.
12
7*5 dy.
12-0

9-6

0-6

80.3*

2-0

1-5

95*7t

95 1*
1-3

13-8t

9-8*
5-5
7*425
0044
31.7*
6-7

8-2
4-5
7*378
0043
36*4

8-7

7*434
0054
31.3*
6-7

-3*

30

15*7*

2-4

t = p < 0-01,

11-40 Dy.

3-4 Dy.
13
73 hr.
77.8*
16-4

-9*

2-3
14-3
4-8
*

4-2
-

25*

2-3
13-3
1-8

8
27*5 dy.

77*8t

960Ot

8-4
2-9

7*425

Adults
13
30 yr.
91*8
12-4
97-1
1.1
5-5
5-1
7*443

0033

0044

32*9
40

6-4

-1*

2-2
10.9
30

37*9
+ 1*4

1-5
13 0

11

p < 0001.

The base excess was always lower than in adults


(Table II), but the pH was similar, because the
infants were hyperventilating relative to adults, in so
far as the Paco2 at 6-24 and at 25-48 hours of life was
significantly lower than in adults (Table II).

Infants with tachypnoea (Table III and Fig. 4


and 5). At 6-24 hours of life these babies had a
significantly lower P5o2, S5o2, and pH, and a
significantly higher P5co2 than normal prematures
of the same age (Table III). VA was higher than
normal, but not significantly so.
As in the normal group, there was an increase in
Pao2 and Sao2 and a decrease in VA from 6-24
hours to 3-10 days of age (p < 0 01).

Infants with mild respiratory distress


(Table III and Fig. 4 and 5). The five prematures
included in this group had a significantly lower than
normal Pao2 and S5o2 and a higher VA at 6-24
hours of age. These abnormalities were still
present on the second day of life, and disappeared
thereafter. As in the other groups, the changes in
Pao2, Sao2, and VA from 6-24 hours to 3-10 days
of age were statistically significant (p < 0 01).

50-

'

12
Hours

24

48 3 4
'

'

10 20 30 40
Days

Adults

Aqe

FIG. 1.-Mean (+ SD) arterial oxygen tension in 'normal'


premature infants at different ages.

Discussion
The results of the present study are compared
with data derived from previous publications in
Table IV.
We have confirmed the presence of decreased
arterial oxygenation in the newborn period in

Arterial Oxygen Studies in Premature Newborns

177

100-

*~~~~*s

95

00

@0

0*

4*

0*

00

;o
C1

c0

901

0*

85

6
-

Age

12
Hours

48 3_ i
'

24
-

0
'

20

30
Day s

40

50

Adults

FIG. 2.-Arterial oxygen saturation in 'normal' premature infants of different ages. Means + SD are shown.

'normal' premature infants and have found that the


decrease in PaO2 and SaO2 is not generally greater
than in full-term infants. Our data show that
oxygen unsaturation persists in premature infants
until the end of the first month.
After the first 5 hours of life alveolar hypoventilation cannot account for the low P.o2 and SaO2 in
'normal' premature infants, since the PaCo2

remained below adult values. The presence of a


large percentage of venous admixture in 'normal'
premature infants implies the existence of one or
more of three deficits of physiological function: a
right-to-left shunt of blood, inequalities of ventilation to perfusion, or a diffusion defect. In the
absence of studies during oxygen breathing it is
impossible to be certain which of these deficits was

307

25

20-

-0

cx
*
vs

10-

*-

%a

_r.
.__

0
'

12

Hours

24

*
0

SI-

.
.
.
.1
._
.,T

48
'

3 4
'

10

20

30

40

S0 Adults

Days

Aqe

FIG. 3.-Venous admixture in air of arterial blood in 'normal' premature infants of different ages. Means
SD are shown.
6

Orzalesi, Mendicini, Bucci, Scalamandre, and Savignoni

178

TABLE III
Arterial Blood Values in 3 Groups of Premature Infants Studied at Different Ages (Means SD)

..
Number ..
..
Age (mean)
P&O2 (mm. Hg) ..

SaO2() * -

VA(%)

..

..

Paco2 (mm. Hg) ..


BE (mEq/l.)

..

Hb (g./100 ml.) ..

Tachypnoea

Tachypnoea

Normal

RDS

RDS

Normal

Tachypnoea

RDS

21

11

22

25

15 hr.

12-5 hr.

15 hr.

35 hr.

34-5 hr.

41 hr.

5-5 dy.

5-4 dy.

5-5 dy.

57*3
13-8

79*0
99

76*8
12-7

71*1
5-3

93.1*

95 *4
1-5

1-6

1-4

9 0
5 0

6-3

10 0

2-2

35-7
4-8
-39
2-5

9 7
3-1
7*398
0044
40*6
7-3
-19
3-4

13-8
3-6

14-3
1-8

14-4
1-2

68 2
13-4
95 2
1-7
156
5-7
7448
0-069
27-5
7-8
3-7
3-3
16-0
2-5

pH.

3-10 Dy.

25-48 Hr.

6-24 Hr.

Normal

58.7*

10-2

920*t

2-5

52.5*

72*5

12-4

20-9

59 *7
15-0

2-0

902*

95 *0
2-0

2-3

1 0

17-5
5-4
7*395
0-022
34-4
109

93*7

9 3

8-3

28-7t

13-8
8-7

18-9
7-5

7*380t

7*381
0-062

7*420
0-023

36-9t

33-2

7*434
0054
31-3
6-7
-2-3
30
15 7
2-4

21-4

0-022

7-3
5-3
2-8
16-2
0-2

7-1
3-7
2-1

155
2-3

309
3-7
3-5
2-2

3-7

2-6
14-1
1-4

14-3
1.0

94*8

94*8

7*402
0049
339
59
-3-2

7*378
0-038

Values significantly different from 'normal' of the same age: * = p < 005; t = p < 0 01; * = < 0 001.

present in the babies studied. Nelson and coworkers (1963) and Prod'hom and co-workers (1964)
have demonstrated, in newborn infants with a
higher birthweight, a large right-to-left shunt. On
the other hand, from the data of Moss and coworkers (1965), it can be calculated that a true rightto-left shunt cannot account completely for the low
P102 and S502 in premature infants breathing room
air; this implies that a ventilation-perfusion
imbalance (or possibly a diffusion defect) is also
present.

The infants with tachypnoea were hypoventilating


when compared with the normal prematures (the
Paco2 was higher), and in addition their venous
admixture was greater. These two changes account
for the lower oxygen tension and saturation in these
infants.
In the prematures with mild respiratory distress
the venous admixture was greater than in either of
the other groups, a finding that probably reflects a
larger right-to-left shunt and also inequalities of
ventilation and perfusion. As the arterial Pco2 was

100

o-o Normal
* --.@CTachypnoea

30-

A----A

Resp.distress

1--~~~~~~~~~~~~~0

90-

20-

O--O Normal

10 -

*.-.--aTachypnoea
A----A

80-

0
Aqe (days)

II

Resp.distress

10

--I

3b

0
0

10

30

Aqe (days)

FIG. 4.-Arterial oxygen saturation at different ages in the


3 groups of premature infants studied. Means + SE are

shown.

FIG. 5.-Venous admixture in air of arterial blood, at


different ages, in the 3 groups of premature infants studied.
Means SE are shown.

Arterial Oxygen Studies in Premature Newborns

179

TABLE IV
Comparison of Present Data with Those Found by Other Authors in Normal Full-term and Premature
Newborn Infants
Author
Stahlman (1947)
(Femoral artery)

Birthweight
(kg.)

Gestation
(wk.)

No.
0.

Age
(hr.-dy.)

Pa02Hg)
(mm.

3 -23
(2*50-4*08)

Full-term

16-5 hr.
(9-22)
34 hr.

93 0

7-434

30 9

94*6

31 -3
29 -2

15
11
6

(29-48)
58 hr.
(50-72)
82 hr.

SaO2
(%

pH

PaCO2
(mm.
Hg)

94*6

92-9

7*424
7 429
7*465

94-7
93-2

7-341
7-408

38 -3
336

94*9

7*306

38-3

VA
(o

30*5

______________(75-96)

Weisbrot et al. (1958)

2-50

Full-term

7
14

Reardon et al. (1960)


(Temporal artery)

3 *15

Full-term

17

(Left atrium)

(2*30-3*90)

6
27
6

20
7

Prod'hom et al. (1964)

(Umbilical artery)

3-18

(2*27-4*31)

36-5
(35-39)

36
6
20

19

14

Moss et al. (1965)


(Ascending aorta)

2*02
(1 36-2*33)

6
15
20
7

Present data

(Umbilical, temporal, and

1*76
(1 26-2 48)

34*5
(28-40)

4
21

22
25
8

normal (or even low) in these infants, hypoventilation


was not a factor in the production of arterial oxygen
unsaturation.
The results of this study are consistent with the
view that right-to-left shunting of blood and
maldistribution of gas with respect to blood flow are
common in premature infants, and may persist
throughout the first month of life. When the infants
are asymptomatic these abnormalities do not seem
greater than in full-term infants, but in the presence
of clinically apparent symptoms (tachypnoea or
mild respiratory distress, even with normal chest
x-ray films) more severe derangements of function are
present.

3 hr.
24 hr.
2*6 hr.
(1-4)
7O-0hr.

(4-10)
1l hr.
(6-24)
38 hr.
(30-45)

45 hr.
(30-48)
97 hr.

(76-112)
86 hr.
(72-96)

85 *3

94*1

7*368

78 8

94*4

7 *386

87*0

94*5

7*379

7*390

34 -4
-

33 -9
-

5 dy.
1 hr.

94*9

61-0

7-310

36 -3
35 *2
46-0
31

4 hr.
24 hr.

72 *0
71-0

40*0
36-0

20

7 *370
7430

9 hr.
(2-12)
18 hr.

68*5
61*3
75 *9
77 7

94*0
93*5
94*7
94*3

7*376
7*391
7*394

32*7
29*8
29*3

17
16

7 356

31*9

11

59*5

91*3

7 *329

47 *3

20

15 hr.

68 *2

7*448
7*434

16

72 *5

95 *2
95 *0

27 *5

35 hr.

31*3

79*0

95 *4

77 8

96-0

7 *402
7-425

14
9
8

(13-24)
34 hr.
(25-48)
67 hr.
(49-120)
4 hr.
(3-5)

(6-24)
(25-48)
5-5 dy.
(3-10)
27-5 dy.
(11-40)

33*9

32-9

20

15

Summary
Arterial oxygen and carbon-dioxide tension (Pao2
and Paco2), pH, base excess, and Hb concentration
were measured in 59 premature infants from 3 hours
to 40 days of age and in 13 normal adults; oxygen
saturation (SaO2) and venous admixture in air (VA)
were also calculated. The babies were divided into
3 groups.
In a group of 40 'normal' prematures SaO2 did not
change appreciably after 5 hours of age, whereas
there was a significant rise in PaO2 and a fall in VA
from 6-24 hours to 3-10 days of life. PaO2 and SaO2
at all ages were significantly lower than in normal
adults.

180

Orzalesi, Mendicini, Bucci, Scalamandre, and Savignoni

A group of 14 prematures with tachypnoea had


significantly lower PaO, and SaO2 and higher Paco2
at 6-24 hours of life when compared to normal
prematures of the same age.
A third group of 5 prematures who showed mild
transient respiratory distress had lower than normal
PaO2 and SaO2 and higher VA at 6-24 hours of age.
These abnormalities were still present on the second
day of life.
The significance and the implications of these
findings have been discussed.
REFERENCES

Adams, F. H., Fujiwara, T., Spears, R., and Hodgman, J. (1964).


Gaseous metabolism in premature infants at 32-34 C. ambient
temperature. Pediatrics, 33, 75.
Adamsons, K., Jr., Daniel, S. S., Gandy, G., and James, L. (1964).
Influence of temperature on blood pH of the human adult and
newborn. J. appl. Physiol., 19, 897.
Astrup, P., Jorgensen, K., Siggaard Andersen, O., and Engel, K.
(1960). The acid-base metabolism: a new approach. Lancet,
1, 1035.
Bradley, A. F., Stupfel, M., and Severinghaus, J. W. (1956). Effect
of temperature on Pco2 and Po2 of blood in vitro. J. appl.
Physiol., 9, 201.
Bucci, G., Scalamandre, A., Savignoni, P. G., Orzalesi, M., and
Mendicini, M. (1966). Crib-side sampling of blood from the
radial artery. Pediatrics, 37, 497.
Comroe, J. M., Forster, R. E., Dubois, A. B., Briscoe, W. E., and
Carlsen, E. (1962). The Lung, 2nd ed. The Year Book
Publishers, Chicago.
Edwards, M. J., and Ross, B. B. (1959). Graphical representation
of respiratory gas dissociation characteristics of fetal and
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Addendum
After this paper was accepted Thibeault, Clutario, and
Auld (1966) found similar results to ours.
RaRaENCa
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oxygen tension in premature infants. J. Pediat., 69, 449.